It was three and half years ago that Helen Hunt brought cheers from movie audiences across the country when she spat out a string of expletives with the acronym "H.M.O." nestled in the middle of it. She got the Academy Award for Best Actress ("As Good As it Gets"), and the industry's image has continued to slide downhill.

The system of managed care -- getting our health care through HMO's and other large insurers -- has failed. For a while in the 1990s it seemed like these organizations could solve the one problem that employers worried about -- containing costs. But now insurance premiums are rising at double-digit rates again. In the mean time the care managers' attempts at cost-cutting seem to have succeeded only in angering millions of Americans, while simultaneously enriching some very highly paid executives. (William McGuire, CEO of UnitedHealth Group, led the pack with $54.1 million in compensation last year, adding to his $358 million accumulation of stock options.)

But the exorbitant rewards at the top of the managerial pyramid are only a small fraction of the waste that makes our health care system the most expensive in the world. We spend nearly 14 percent of our national income on health care, while the average for other high-income countries is about 8 percent. And unlike other rich countries, we leave one out of six of our citizens -- 43 million people -- without health insurance.

This result is altogether predictable from a system that has private insurers competing to cover the healthiest prospects and abandon, as much as they can, the sick. You don't need a degree in actuarial science to see that this is the most effective way for an insurer to make money, even it means devoting enormous resources to these non-health-care goals.

The legislation now slogging through Congress will add another layer or two of oversight -- including the court system -- on top of the existing bureaucracy. Despite the additional costs, this will be an improvement, since there needs to be some way under the present system to hold the managed care industry accountable. If the bill makes it through the House without too much amputation, there will be some added rights for at least some of the insured. These include the right to external review when treatment is denied, the right to sue insurers for denial of covered care, and the right to visit the nearest emergency room.

But the Patients' Bill of Rights will not help the uninsured, or tens of millions more -- including chronically ill patients paying exorbitant premiums -- that are underinsured. To solve these problems, and to contain costs, we will need a universal health insurance system, with the government as the insurer.

The case for social insurance is a simple one, based on the human condition and some fundamental economic logic. First, we all get old and sick eventually, so it's best to insure against these hardships when we are young, healthy, and working. Second, the most efficient way to do this is to put everyone into one big "risk pool" -- it saves enormously on overhead costs. If you don't believe this, just compare the administrative costs of Social Security -- which provides social insurance for retirement, life insurance, and disability -- to those of the private life insurance industry: 0.8 percent versus 12 percent. And lastly, health care is not a commodity like a DVD player, but a basic human need. A decent society does not let its fellow humans go without it.

Medicare was an attempt to extend the principles of social insurance, which have been so successful in the realm of Social Security, to health care for the elderly. At the time (1965) it was assumed that this would soon be extended to the rest of the population.

The failure to achieve this goal reflects a failure of our political system, a somewhat limited form of democracy in which insurance and pharmaceutical giants purchase -- with their political contributions -- the right to a veto over health care policy. Last year the pharmaceutical companies spent $30 million for a blitz of very successful TV ads, in order to block President Clinton's attempt to create a prescription drug benefit for Medicare.

Now the insurance industry is deploying its army of lobbyists to gut the Patients' Bill of Rights, as much as it can. But with the economy slowing and health care costs rising at unsustainable rates, it is only a matter of time until real health care reform -- with universal social insurance -- is back on the political agenda.